Self Instructional Manual for Cancer Registrars - SEER - National ...

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EXAMPLE G6 PATHOLOGY REPORT Name Ben Hurtin Path. No. $91-1017 Reg. No. 000042 Age 74 Sex Male Race White Location ._ Service Surgery Date 3[17/91 Address Occupation Farmer HISTORY OF CASE: Melanoma (R) arm; pos (R) axillary node CLINICAL DIAGNOSIS: Melanoma Stage III Surgeon Otto Fixum, MD Operation R axillary node dissection GROSS DESCRIPTION: The specimen is received in two portions. Part 1 labeled "axillarynode, right" consists of a single lymph node with attached fibroadipose tissue. The specimen is bisected and submitted in toto. Part 2 is received in a steel pan. It is labeled "contents, right axillary node dissection." A solitary silk suture identifies the highest axillary level which is separated and designated #3. A portion of pectoralis major muscle measuring 7.0 x 5.0 x 2.0 cm in thickness is attached to this portion. Level II contains a mass 6.5 x 3.5 cm which is firm and on cut surface contains a homogeneous flesh-like mass which is light gray in color and firm in consistency. Photographs are made. Several small nodes are identified in level I which consist primarily of adipose tissue. MICROSCOPIC DESCRIPTION: Sections of 18 lymph nodes revealed in 3 of them diffuse replacement of normal lymphoid tissue by epithelioid-in-appearance malignant cells. The mitotic activity is marked and nuclei disclose prominent pleomorphism. No melanin pigment is identified. DIAGNOSIS: Metastatic malignant melanoma, in 3 of 18 (Level I (one), level II (one), and level III (one)), right axillary lymph nodes. Mac McSmall, MD Pathologist 217
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SEER Program Self InstructionalManu
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TABLE OF CONTENTS BOOK 5: ABSTRACTI
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SECTION A OBJECTIVES AND CONTENT OF
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SECTION B THE COMPOSITION AND ORGAN
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Physical Examination General (gener
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FORMS USED TO RECORD INFORMATION IN
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SECTION C ABSTRACTING A MEDICAL REC
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WHEN TO ABSTRACT CASES While it may
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Local Registry Number A patient's r
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Marital Status Select appropriate a
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Abstracting Diagnostic Procedures S
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SECTION D DIAGNOSTIC PROCEDURES: GE
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SECTION E CLINICAL EXAMINATIONS: PH
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EXAMPLE E1 Name: Sarah O. Luckless
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EXAMPLE E2 Name: Hector Breathless
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BODY SECTION RADIOGRAPHY. Body sect
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E. Lower GI Series or Barium Enema:
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Example E3 can be abstracted as fol
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Example E6 might be abstracted as f
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EXAMPLE E9 Name: Hardy Smooker Hosp
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Examples E8-E10 can be abstracted a
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EXAMPLE Ell Name: Emma Bronchilli H
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DIAGNOSTIC NUCLEAR MEDICINE EXAMINA
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EXAMPLE El2 THE DIVISION OF NUCLEAR
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EXAMPLE E14 Record No.: 000014 Name
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MAGNETIC RESONANCE IMAGING: Magneti
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EXAMPLEE16 MRI CONSULTATIONREPORT N
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HEMATOLOGIC EXAMINATION A hematolog
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Granulocytes or granular leukocytes
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Certain types of disease associated
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EXAMPLE E17 HEMATOLOGY LABORATORY N
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EXAMPLEE18 HEMATOLOGY LABORATORY Na
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EXAMPLE E19 HEMATOLOGY LABORATORY R
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PRACTICAL EXERCISE ANSWERS Example
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Bone Marrow Studies. Examination of
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EXAMPLE E20 Name: Bo Comeaway Hospi
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Example E20 can be abstracted as fo
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Blood Serum Studies Automation and
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Other Laboratory Studies Marrow Aci
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Totalprotein. This test measures th
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SECTION F MANIPULATIVE AND OPERATIV
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SECTION F MANIPULATIVE AND OPERATIV
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EXAMPLE FI Rec. No. 000019 Name Iv_
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The manner in which the findings in
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EXAMPLE F2 LARYNGOSCOPY REPORT Hosp
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The illustrated report can be abstr
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I EXAMPLE F3 REPORT OF CYSTOSCOPY N
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Example F3 is abstracted as follows
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EXAMPLE F4 GASTROINTESTINAL DIAGNOS
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The information described in Exampl
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EXAMPLE F5 SIGMOIDOSCOPY REPORT Rec
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EXAMPLE F6 PROCTOSCOPY REPORT Rec.
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EXAMPLE F7 GASTROSCOPIC REPORT Hosp
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EXAMPLE F8 GASTROSCOPIC REPORT Hosp
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EXAMPLE F9 BRONCHOSCOPY REPORT Hosp
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EXAMPLE FIO BRONCHOSCOPY REPORT Hos
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EXAMPLE Fll BRONCHOSCOPY REPORT Hos
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EXAMPLE F12 BRONCHOSCOPY REPORT Hos
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PRACTICAL EXERCISE ANSWERS These en
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Example F10: 5/5/91. Bronchoscopy:
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In all of the "oscopies" described
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EXAMPLE F13 OPERATIVE REPORT Name:
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This operative report may be abstra
Page 172 and 173: OPERATIVE PROCEDURES Exploratory_Su
Page 174 and 175: EXAMPLE F14 OPERATIVE REPORT Servic
Page 176 and 177: The operative record used as an ill
Page 180 and 181: Example F15: 3/11/91. Expl. Lap.: L
Page 182 and 183: PRACTICAL EXERCISE The following pa
Page 188 and 189: These operative reports can be abst
Page 190 and 191: EXAMPLE F18A OPERATIVE REPORT Name
Page 192 and 193: EXAMPLE F18B OPERATIVE REPORT Name
Page 194 and 195: Example F18 can be abstracted as fo
Page 196 and 197: SECTION G PATHOLOGICAL EXAMINATIONS
Page 198 and 199: SECTION G PATHOLOGICAL EXAMINATIONS
Page 200 and 201: A. The BiopsyReport The termbiopsy(
Page 202 and 203: EXAMPLE G1 DEPARTMENT OF PATHOLOGY
Page 204 and 205: Example G1 can be abstracted as fol
Page 206 and 207: Abstracting the Pathology Report Le
Page 208 and 209: EXAMPLE G2 PATHOLOGY REPORT Path. N
Page 210 and 211: EXAMPLE G3 PATHOLOGICAL SPECIMEN RE
Page 214 and 215: EXAMPLE (34 (continued) DIAGNOSIS:
Page 218 and 219: The information which should be abs
Page 220 and 221: PRACTICAL EXERCISE In the following
Page 230 and 231: PRACTICAL EXERCISE ANSWERS Example
Page 232 and 233: EXAMPLE G10 AUTOPSY REPORT IDENTIFI
Page 234 and 235: EXAMPLE G10 (continued) CLINICOPATH
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Page 238 and 239: EXAMPLE Gll DEPARTMENT OF PATHOLOGY
Page 240 and 241: EXAMPLE G11 (Continued) DEPARTMENT
Page 242 and 243: EXAMPLE Gll (Continued) DEPARTMENT
Page 244 and 245: Example G11 can be abstracted as fo
Page 246 and 247: CYTOLOGIC EXAMINATION The study of
Page 248 and 249: A cytology report recorded as suspi
Page 250 and 251: PRACTICAL EXERCISE Summarize the fi
Page 252 and 253: EXAMPLE G13 i ! PATIENT NO. DATE 10
Page 254 and 255: EXAMPLE G14 Patient No. 000050 DATE
Page 256 and 257: EXAMPLE GI_ CLINICAL RECORD - TISSU
Page 258 and 259: Examples G12-15 may be abstracted a
Page 260 and 261: COMMON ABBREVIATIONS Abbreviation T
Page 262 and 263: HEENT Head, _ eara, ame & throat LE
Page 264 and 265: SARC Sarcoma UMB Navel (umbilicus)
Page 266 and 267: COMMON ABBREVIATIONS Definition Ind
Page 268 and 269: Impression IMP Lumbar spine L-SPINE
Page 270 and 271: Staphylococcus STAPH Within normal
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COMMON SYMBOLS Symbol Index Symbol
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ACRONYMS FOR ORGANIZATIONS CONCERNE
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WORLDWIDE ORGANIZATIONS IACR Intern
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ACRONYMS FOR STUDY GROUPS The follo
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SELECTED BIBLIOGRAPHY Cancer Regist
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INDEX Abstract, 3, 9, 11, 15-17, 21
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Cerebral angiogram, 40 Chemistry (S
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Endoscopic examination (Cont'd) Exa
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Laryngogram, 65, 69 Example E9, 65,
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Papanicolaou classification, 243 Pa
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Special examinations, 8 SPECT, 71 S
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Index of Examples E_mmple E1 29, 31
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